透析準備不適當與不佳的存活風險有關

作者：Deborah Brauser  
出處：WebMD醫學新聞

　　April 30, 2010 (佛州奧蘭多) — 根據發表於NKF 2010春季臨床會議針對超過190,000名病患進行的回溯評估結果，符合國家腎臟基金會(NKF)三個透析準備指引目標的末期腎臟病患，比那些不符合者有顯著較佳的存活。
　　
　　明尼拿坡里VA醫學中心腎臟科醫師、明尼蘇達大學腎臟與高血壓科內科助理教授Yelena Slinin醫師報告指出，更令人驚訝的是，發現59%的病患連一個目標都不符合。
　　
　　Slinin醫師在新聞稿中表示，透析前照護這個領域的研究多數聚焦在讓病患及早接受腎臟專科醫師診治，以便有適當的時間進行透析準備。
　　
　　Slinin醫師在Medscape Nephrology的訪問中表示，不過，根據我們的研究，即使是已經轉給腎臟專科醫師一年的病患，接受透析時的準備仍不佳。
　　
　　來自NKF「腎病結果品質初步調查」的這三個透析前目標，包括病患完成一個有效的手術且較少容易發生感染的血管路徑；有適當的血紅素值(以對抗貧血)；以及有適當的血中白蛋白值(確保營養良好)。
　　
　　Slinin醫師報告指出，動靜脈廔管不太可能導致感染且持續較久，廔管和動靜脈移植物這兩者比洗腎導管產生較佳的結果，遺憾的是，洗腎導管是開始透析時最常用的血管路徑。
　　
　　【很少病患符合目標】
　　Slinin醫師等人評估了美國192,307名20歲以上病患的資料(平均年紀64.5歲)，這些人在2005年6月至2007年5月間開始透析，研究者試圖檢視那些達到這三個NKF目標者的第一年存活是否較佳。
　　
　　結果顯示，只有1%的病患符合全部的三個目標，9%符合兩個，31%只有符合一個，59%沒有符合任何目標。
　　
　　研究者也發現，符合越多目標，則透析的第一年越可能存活。相較於那些沒有符合任何目標者，符合一個目標者的死亡風險降低19%，符合兩個目標者之風險降低47%，符合全部三個目標者的風險降低66% (全部的P都小於.001)。
　　
　　Slinin醫師報告指出，而且，使用動靜脈移植物或廔管者，因感染而死亡的比率減少44%，透析開始時使用血管路徑、而不使用導管，可以預防許多早期感染致死案例。
　　
　　此外，符合血紅素目標(≧11 g/dL)者的校正死亡風險比率為0.94 (95%信心區間[CI]為0.92- 0.96)，符合白蛋白目標者為0.67 (95% CI，0.65- 0.70)。
　　
　　Slinin醫師表示，換句話說，適當的白蛋白值降低死亡率達33%、適當血紅素值則將其降低6%，我們的研究強調透析前照護的幫助，且呼籲釐清影響透析準備的可能障礙，我們身為腎臟專科醫師，應該可以做得更好，還有許多改善空間。
　　
　　她表示，她接下來要研究為什麼這麼少人符合這些指引目標，她認為受到許多許多因素影響，希望加以釐清這些因素以便介入和改善。
　　
　　【引起注意】
　　NKF下任理事長、杜克大學內科副教授Lynda Szczech醫師表示，我認為這最引人注意的是，將這些基準轉變成品質改善指標。
　　
　　未參與此次分析的Szczech醫師表示，事實上，撇開只有少數病患符合目標不談，這是個有趣的研究，有確實根據且值得我們注意。
　　
　　她指出，她最大的考量是，有許多目標並不是100%在醫師的控制之下。
　　
　　Szczech醫師結論表示，整體而言，我認為最重要的事情之一是，我們需要在腎臟學界落實，這篇研究引人對其之注意，也讓第三方付費者瞭解到，我們自己定義的臨床表現指標無法一字不漏地轉成給付方的良好照護品質。
　　
　　US Renal Data System的Chronic Disease Research Group提供部分資料協助。Slinin醫師指出，部分資金來自Minneapolis VA的年輕教職員臨床流行病學計畫。. Szczech醫師報告擔任Medicare和 Medicaid Services兩家保險中心的技術諮詢小組 ，從中接受報酬。
　　
　　國家腎臟基金會(NKF) 2010春季臨床會議：壁報摘要236，發表於2010年4月14日。


Improper Dialysis Preparation Associated With Poor Survival Risk

By Deborah Brauser
Medscape Medical News

April 30, 2010 (Orlando, Florida) — Patients with end-stage kidney disease who meet the National Kidney Foundation's (NKF) 3 dialysis initiation guideline goals have a significantly better survival advantage than those who don't, according to the results of a retrospective evaluation of more than 190,000 patients, presented here at the NKF 2010 Spring Clinical Meetings.

More surprising was the finding that 59% of the patients didn't meet even 1 of the goals, reported Yelena Slinin, MD, assistant professor of medicine in the Division of Renal Diseases and Hypertension at the University of Minnesota in Minneapolis, and staff nephrologist at the Minneapolis VA Medical Center.

"Most of the research in the area of predialysis care has focused on getting patients to see kidney specialists early to allow for adequate time for dialysis preparation," said Dr. Slinin in a news release.

However, "according to our research, even patients who have been seen by kidney specialists for over a year come to dialysis poorly prepared," Dr. Slinin added during an interview with Medscape Nephrology.

The 3 predialysis goals from the NKF's Kidney Disease Outcomes Quality Initiative are that patients have a procedure done for effective and less infection-prone vascular access; have adequate levels of hemoglobin (to fight against anemia); and have adequate levels of blood albumin (to ensure good nutrition).

Arteriovenous fistulas are least likely to lead to infection and are longer lasting, and both fistulas and arteriovenous grafts produce better outcomes than tunneled dialysis catheters, reported Dr. Slinin. "Sadly, that is the most common vascular access at dialysis initiation."

Few Patients Meet Goals

Dr. Slinin and her team evaluated data from a cohort in the United States of 192,307 patients older than 20 years of age (mean age, 64.5 years) who started dialysis between June 2005 and May 2007. They sought to examine whether those who attained the 3 NKF goals had a first-year survival advantage.

The results showed that only 1% of the patients met all 3 goals, 9% met 2, 31% met just 1, and 59% met none of the goals.

The investigators also found that the more goals met, the more likely a patient was to survive their first year on dialysis. Compared with those who met none of the goals, those who met 1 goal had a 19% lower risk for death, those who met 2 goals had a 47% lower risk, and those meeting all 3 goals had a 66% lower risk (P?< .001 for all).

"Also, patients who had an arteriovenous graft or fistula in place had mortality reduced due to infection by 44%," reported Dr. Slinin. "Many of the early infectious deaths can potentially be prevented by having vascular access other than catheter at the start of dialysis."

In addition, the adjusted mortality hazard ratio for meeting hemoglobin at goal (>11?g/dL) was 0.94 (95% confidence interval [CI], 0.92?- 0.96) and for meeting albumin at goal was 0.67 (95% CI, 0.65?- 0.70).

"In other words, optimum albumin levels reduced mortality by 33% and adequate hemoglobin reduced it by 6%," said Dr. Slinin. "Our study emphasizes the benefit of predialysis care and the urgent need to define potential barriers to dialysis preparedness. We, as nephrologists, can do a better job; there is a lot of room for improvement."

She said that she would next like to study the reasons so few of these guideline goals are being met. "I think there are multiple, multiple factors that are playing into it, and what I want to do is tease those out so that we can intervene and improve things."

Drawing Attention

"I think this draws attention to one of the biggest concerns I have in translating benchmarks to quality improvement metrics," said incoming president of the NKF, Lynda Szczech, MD, associate professor of medicine at Duke University Medical Center in Durham, North Carolina.

"The fact that few of their patients met the goals aside, this study is interesting, it's valid, and it's something that we should look at," said Dr. Szczech, who was not involved with this analysis.

She noted that her biggest concern is that there is a lot about the goals that are not 100% within the control of the physician.

"Overall, I think one of the biggest things that we need to do in the renal community, and this [study] really draws attention to it, is to make third-party payers aware that the clinical performance benchmarks that we define for ourselves do not translate verbatim into good quality care on the payment side," concluded Dr. Szczech.

Some data assistance was provided by the Chronic Disease Research Group at the US Renal Data System. Dr. Slinin reports receiving some support from a clinical epidemiologic program for young faculty at the Minneapolis VA. Dr. Szczech reports serving on the technical advisory panel for the Centers for Medicare and Medicaid Services, from which she received an honorarium.

National Kidney Foundation (NKF) 2010 Spring Clinical Meetings: Abstract Poster?236. Presented April?14, 2010.